What Medicare Advantage Plans Want From Home-Based Care Providers

Medicare Advantage (MA) has provided tailwinds for home-based care providers, as the overall MA member population has grown substantially over the last decade.

In 2020, there were over 24 million MA members in the U.S., over double the amount there were in 2010 and nearly five times the amount in 2005, according to Centers for Medicare & Medicaid Services (CMS) data.

MA opportunities don’t grow on trees, however. Home-based care agencies are undoubtedly worthy in the continuum of care, but each provider has to prove its value to health plans looking to reduce costs and provide better care for their members.


And from the health plan perspective, there is more than one thing they’re looking for, Greg Sheff, the SVP and CMO of Home Solutions for Humana (NYSE: HUM), said on a recent webinar hosted by the Advisory Board.

“One thing is coming with outcomes data,” Sheff said. “From the payer’s perspective, we’re going to look at that and be cynical about it. [We’ll] want to test it and validate it with our own pilots with [the provider]. But talking about outcomes — and not just kind of the pitch on the model — is super important.”

The Advisory Board is a research, technology and consulting firm that works to improve the performance of health care organizations.


The Louisville, Kentucky-based Humana is one of the largest MA plans in the country. It has also become one of the largest providers of in-home care, namely through its acquisition of Kindred at Home. Its at-home businesses also includes partnerships with the hospital-at-home provider DispatchHealth and the at-home primary care provider Heal.

In addition to Humana, other large MA plans include UnitedHealthcare (NYSE: UNH) and Blue Cross Blue Shield and its affiliates. In total, 3,550 Medicare Advantage plans are available nationwide for individual enrollment in 2021, a 13% increase from 2020, according to the Kaiser Family Foundation.

Data procurement — though one of Sheff’s main recommendations — has not been a strong suit for home care agencies historically. Many providers either don’t have the bandwidth to invest in that type of data collection, or they haven’t found it to be useful in taking care of their patients.

Overall, 75% of home care agencies did not track readmission rates at all in 2019, according to data from Idaho-based market research and education firm Home Care Pulse. Of the 25% that did, it was often rudimentary data tracking.

Still, Sheff believes that data is only one leg of the race to getting payers’ attention.

“The other thing [that’s important] is a little bit more conceptual,” he said. “It’s having specific interventions with specific protocols, specific training, pathways and leading indicators that show us that the thesis of what you … do is going to move the dial.”

An example: If a home-based chronic kidney disease management company was pitching Humana, and part of its thesis was engaging patients with a nephrologist early on.

“We need to see that your members are actually seeing the nephrologist before we start worrying about the dialysis or what the readmission rates are,” Sheff said. “So again, thinking up those leading indicators and making sure you’ve mapped them out.”

It’s also important that home care organizations explain how they’re different from their peers. A generic plan of care team in the home could potentially cut it for some payers, but at least from Humana’s perspective, it won’t.

Come with questions

Providers could bring all kinds of wonderful solutions to the table when meeting with a payer, but they still may gain no headway. To avoid that, in-home care organizations should start by analyzing payers’ pain points.

That’s according to Michael Johnson, the president of the home health and hospice practices at Bayada Home Health Care.

“Come trying to figure out what the pain point is and what the problems are for the payer,” Johnson said. “Because we may be all excited about our outcomes in a certain geography, but only 10% of the people in that population are members of that MA plan [we’re talking to]. So for us, it’s about how we gear it toward a meeting that’s meaningful for the payer.”

Moorestown, New Jersey-based Bayada is one of the largest home health providers in the country. As part of the nonprofit’s network, it has more than 360 offices in 23 states, with additional locations in Germany, India, Ireland, New Zealand and South Korea.

The process sounds simplistic, but in the end, a provider could have all the capabilities a payer needs and still not form a partnership because it failed to recognize that MA plan’s needs at the time.

“In the end, the ability to be successful is going to require two-way communication,” Johnson said. “Because if there’s a problem, we want to come back to our payer partner with [a solution]. It comes down to understanding each other, and quite simply having a relationship where when the chips are down, you’re going to sort of say, ‘We’re going to figure this out.’”

In an ideal payer-provider relationship, both will reap the benefits financially.

That’s the point of procuring the data and forming the best thesis and pitch to an MA plan, after all. But in the meeting, it’s best if the conversation does not start with the provider seeking out financial incentives from the payer, Johnson said.

“Whatever solution you bring, make sure it’s budget neutral,” he said. “Start there and demonstrate that you can make a difference in outcomes that aren’t going to have a negative financial impact on the payer before you start asking for shared savings and so forth. Put your money where your mouth is, [essentially]. I found that’s a much better way to open the door versus, ‘Hey, how much are you going to pay us when we get your readmission rate down?’”

Bayada has had plenty of success contracting with health plans on its end. In March 2019, for example, it announced a major value-based agreement with AmeriHealth Caritas.

There’s more MA members and more MA plans than ever, and that offers a great chance for home health and home care providers to open their services up to a larger population as home-based care becomes more popular.

But having a plan — beyond explaining the positives of caring for people at home — is paramount.

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